HEALTH USE ONLY:
DATE RCD__________
APP______DIS_______
INITIALS___________
Mecklenburg County Health Department
Pool Drain Safety Compliance Form
Facility Name __________________________________________________________________ Pool ID#_____________
Physical Address ____________________________________________________City __________________ Zip _______
All applicable sections of the form must be completed. Missing or incomplete data or information will result in a DISAPPROVAL
of the submission.
1.
Pump System Flow
Pump Manufacturer _____________________________ Model #______________________________ HP________
(Complete either A or B below, not both)
A. Maximum Pump Flow (manufacturer’s specs) ___________ gpm based on pump performance curve
B. Maximum Pumping System Flow is reduced to _____________ gpm based on either(choose one only):
Measured Total Dynamic Head loss of __________ feet;
Calculated Total Dynamic Head loss of __________ feet;
Magnetic flow meter reading of ___________gpm;
Automatic flow limiting valve factory set at ________gpm
***Must provide supporting evidence for flow reduction***
Note: If the pool has more than one type of pump, attach additional sheets with additional pump information.
2.
Drain Sump Measurements
Sump size (inside dimensions): _______ Inches Diameter (if round)
Sump minimum depth __________ inches
______ inches by_______ inches (if rectangular)
Diameter of suction outlet pipe to pump ____________ inches
Distance of top (inside) of suction outlet pipe from bottom of cover/grate _____________ inches
Note: SKIP this section if universal drain cover, approved for sumpless pools, is installed.
3.
Drain Cover/Equalizer Data
Number of main drains on same pumping system ____ Distance between drains (on centers) ______inches (“NA” if single drain)
Drain cover manufacturer ___________________________ Model # _________________ Date Installed __________________
Maximum flow rating of cover/grate___________ gpm (floor); ___________gpm (wall)
Number of operable skimmer equalizers________(each surface skimmer usually has ONE equalizer line)
Equalizer fitting manufacturer ________________________Model #__________________ Date Installed _________________
Maximum flow rating ________ gpm
Pool Exempt:
Gutter 
Spray Pad 
Note: For multiple pumps with multiple drains on one pool, attach additional sheets for each. Ie. Pump #2, Pump #3, etc.
4.
Suction Vacuum Relief System (SVRS) - If applicable, see instructions. Skip if drains are more than 3 ft apart.
SVRS manufacturer ________________________________ Model # _____________
Note: SVRS’s are REQUIRED on all pool pumping systems with either a single main drain or where two or more drains are on
the same pump and are less than 3 ft apart measuring from the center of the drain.
Name of person completing_________________________________________________________Title____________________________
(PRINT)
Signature ____________________________________________________________ Date___________________________
Oct 2014
Instructions for Completion and Submission of Pool Drain Safety Compliance Form
Please review the instructions below to ensure the required Pool Drain Safety Compliance (PDSC) form or its approved
equivalent is properly completed and submitted - detailing all information requested. All submissions will be reviewed and
approved/disapproved by the Health Department. Disapproved submissions will receive written notification of reason(s) for
disapproval.
1. EQUIVALENT FORM – A document which contains the same information requested on the PDSC form and may, or
may not, contain a Professional Engineer’s (PE) or Architect’s sign-off.
2. WHEN/WHERE TO SUBMIT – Updated or new data sheets should be submitted as soon as possible to ensure
timely review. It is recommended they be submitted with the Permit Application. In order to receive an operating
permit in 2015, all Mecklenburg Co. pools must successfully execute the permit application process and receive
approval of their PDSC form. Submissions should be mailed to:
POOL PERMITTING UNIT
Mecklenburg County Health Dept.
700 N Tryon Street, Suite 208
Charlotte, NC 28202
3. WHO CAN SUBMIT – The owner, operator, or any person representing the owner.
4. PUMP SYSTEM FLOW – If estimating maximum flow from a manufacturer’s pump performance curve, attach the
pump curve or assure the pump is listed on the State’s list of pump flow rates. Various pumps can be found listed at:
http://ehs.ncpublichealth.com/faf/pti/drainsafety.htm
5. DRAIN SUMP MEASUREMENTS – Measurements are needed to determine the size of the cover/grate and to
assure the sump is deep and wide enough to meet the requirements in the cover/grate manufacturer’s specifications.
Information on documenting the size of the drain sump can be found at:
http://ehs.ncpublichealth.com/faf/pti/drainsafety.htm
6. DRAIN COVER/EQUALIZER DATA – For maximum flow of main drain covers or equalizer line covers, attach the
manufacturer’s specification sheet or assure the cover is listed on the State’s list of approved covers found at:
http://ehs.ncpublichealth.com/faf/pti/drainsafety.htm
7. SUCTION VACUUM RELIEF SYSTEMS – Devices which are designed to interrupt pump flow if suction outlets
are blocked. More information on SVRS’s can be found on the U.S. Consumer Product Safety Commission (CPSC)
website and the State of North Carolina Public Pool Program website at:
http://www.poolsafely.gov/
http://ehs.ncpublichealth.com/faf/pti/pools.htm
8. FORM COMPLETION – A separate PDSC form must be submitted for each individual pool at a facility including
spas, wading pools, and other pools. Pools with single main drains which attained compliance with State rule changes
made in 2009 are not exempt from compliance with these new standards.
The Health Department understands that the required information and/or measurements may be beyond the scope of
owners or their authorized representatives (pool operators, etc.). In those cases, it is recommended that you contact a
qualified engineer or pool professional to assist you in completing the form.
More information about suctions hazards and pool drain safety may be found on the
State of North Carolina Public Pool program website at:
http://ehs.ncpublichealth.com/faf/pti/drainsafety.htm